INTRODUCTION

Psoriasis is an immune-mediated chronic inflammatory skin disease affecting 2-3% of the adult population globally [1-3]. Chronic plaque psoriasis is characterised by pruritic, well-demarcated, pink plaques (in lighter skin) or grey plaques (in darker skin) covered in silvery scale [1]. There is a strong genetic susceptibility to developing psoriasis; over 80 risk loci have been identified by genome-wide association studies, resulting in a 30% disease heritability [1]. Environmental triggers such as stress, weight gain, smoking, and alcohol consumption play a huge role in disease onset [1]. Lesions can occur anywhere on the body, with common sites including the extensor surfaces of the knees, elbows, trunk, and scalp [1]. Currently, there is no complete cure. Treatment aims to induce remission through topical therapy, phototherapy, oral systemic treatments, and biologics, depending on severity [1, 4].

Immunological studies have suggested that pathogenesis is driven by immune-mediated inflammation primarily through helper T cells type 17 (Th17) and the subsequent production of pro-inflammatory cytokines. This results in the activation of keratinocytes leading to epidermal hyperproliferation and the production of several chemokines, growth factors and other inflammatory molecules setting up a cycle of systemic inflammation [1]. Consequently, psoriasis is well-recognised as a multi-system disease with several co-morbidities such as depression, cardiovascular disease, and inflammatory bowel disease. Involvement of the joints in psoriatic arthritis and nail psoriasis is very common (up to 40% and 90% of patients, respectively) [5, 6]. Both exacerbate the painful and disabling nature of the disease with a significant impact on quality of life. There is a significantly reduced functional status in patients with psoriatic arthritis compared to those with psoriasis alone [7].

Severity of disease, measured by the Psoriasis Area and Severity Index scale (PASI), does not directly correlate with quality of life impairment [8]. There is correlation between mental health and presence of lesions in more visible areas such as the scalp and upper limbs [8]. Severe psoriasis with greater body surface involvement significantly impairs work productivity and daily activities [9]. This can be attributed to the psycho-social burden of the visibility of the disease through low self-esteem, avoidance of social activities, and isolation [10].

The All-Party Parliamentary Group on Skin (APPGS) published a report recognising the increasing burden on mental health from skin disease [11]. 98% of patients felt their skin disease impacted their emotional wellbeing [11]. The report further highlighted the lack of recognition of the emotional wellbeing of patients with 54% of patients being unaware that they could seek help [11]. The available mental health services are limited. However, there is an increasing awareness for the need for expanding psychodermatology services [12].

Given the high impact of psoriasis on patient’s quality of life, it is imperative that research is led by, and addresses, unmet needs reported by both patients and healthcare professionals [13, 14]. The James Lind Alliance (JLA) identified potential misalignment between the priorities of academics, patients, and clinicians [13, 14]. The JLA provides a methodology to establish these research priorities through Priority Setting Partnerships (PSPs) [13, 14], led by steering groups with organisations representing both patients and clinicians that provide collaboration between both stakeholders to outline the most essential questions for future research. PSPs in the United Kingdom for psoriasis and psoriatic arthritis have identified the top 20 and 10 research priorities respectively for these diseases [13, 14, 15]. This narrative review has focused on several key research priorities identified by these PSPs including: the psychological impact of disease, the impact of lifestyle on both treating and causing disease, and the development and management of co-morbidities seen with psoriasis [13, 14, 15].

PSYCHIATRIC CO-MORBIDITIES

Anxiety and Depression

Epidemiological studies have shown the prevalence of depression and anxiety in up to 55% and 48% of patients respectively [16, 17]. Psoriasis patients have a significantly higher rate of depression and suicidal ideations compared to other chronic skin conditions, such as acne, alopecia areata, and atopic dermatitis [18]. All psoriasis patients (regardless of severity) are at a higher risk of depression [19]. There are multiple factors that contribute to this, including pruritus, stigmatisation, and psoriatic arthritis, and there is a higher prevalence of depression and anxiety in patients with psoriatic arthritis compared to those with psoriasis alone [20, 21]. This higher depressive burden can be explained through a higher functional disability from severe joint pain [7].

Consideration of the negative impact on treatment outcomes for patients with depression and anxiety is imperative. Depression in psoriasis is a strong risk factor for poor adherence to treatment. Appropriate management of depression is essential for clinical outcomes of psoriasis treatment [20]. Similarly, anxiety in the form of pathological worrying is a significant factor impairing the clearance of psoriasis through treatment with phototherapy [22]. This can be explained from an increasing body of evidence, from animal and human studies, suggesting that the pro-inflammatory pathways of psoriasis, anxiety, and depression overlap [4]. This creates a bidirectional association and vicious cycle between skin and mental health [23].

Brain-Skin Axis

It is well established that both acute and chronic stress activate the hypothalamic-pituitary-adrenal (HPA) axis, resulting in the production of corticotrophin-releasing hormone (CRH) and further downstream increase in adrenocorticotrophin hormone (ACTH), glucocorticoids, and neuropeptide mediators [24, 25]. CRH itself induces a pro-inflammatory systemic response and is a key mediator between the brain-skin axis; hence it provides a link between psoriasis, depression, and anxiety [24]. Cutaneous corticotrophin-releasing hormone (CRH) peptide and corticotrophin-releasing hormone receptor (CRH receptor hormone) provide CRH binding sites in the skin. This creates a peripheral HPA axis known as the corticotrophin-releasing hormone-proopiomelanocortin (CRH-POMC) system [26]. Through interaction with CRH receptor hormone type 1, CRH stimulates pro-inflammatory cytokines in the skin such as IL-6, IL-8, IL-22, and vascular endothelial growth factor (VEGF) which are also involved in psoriatic plaque formation [24, 27]. Psoriatic skin lesions have a reduced expression of CRH-receptor 1 mRNA compared to healthy controls, which can be explained by overstimulation through local or systemic CRH [28]. Gene expression analysis studies report an up-regulation of POMC mRNA in both lesional and non-lesional skin in psoriasis patients when compared with controls [26].

Regarding treatment, both the cumulative inflammatory effect from psoriasis itself and the negative psychosocial impact from the lesions render it more difficult to treat. Biologics in psoriasis patients improve depressive symptoms along with clinical severity [29, 30]. A recent cross-sectional study comparing oral agents to biologics found significantly higher rates of depression in patients taking oral systemic drugs compared to biologics [31]. Studies do not adjust for obesity or provide sub-group analyses by weight. There is established research that psoriasis patients with a higher BMI struggle to achieve remission with systemic treatment and biologics [32]. Obesity, like depression, induces an additional pro-inflammatory effect through the dysregulation of inflammatory cytokines and adipokines [33, 34]. Further research is required to elucidate the dominant inflammatory components which exacerbate psoriasis in patients with overlapping pro-inflammatory conditions.

Brain Changes

Functional magnetic resonance imaging (MRI) studies have reported that, when shown images of disgusted faces, psoriasis patients have lower levels of activity in the bilateral insular cortex compared to controls [35]. This is attributed to coping mechanisms developed to manage negative social responses to their body. A recent study reported an increased praecuneus thickening using MRI in psoriasis patients with depression [36]. Praecuneus thickening was linked to recurrent lifetime suicidality. However, the study found no significant correlation of praecuneus thickening with systemic inflammation [36]. Positron emission tomography scanning studies have demonstrated no significant increase in neuroinflammatory signals psoriasis between patients and controls suggesting the blood-brain barrier provides a protective role against peripheral inflammation [37].

Suicide

A multi-centre cross-sectional study reported that, among chronic skin conditions, only psoriasis had a significant association with suicidal ideation [38]. In both younger patients and female patients, there is a significantly higher risk of suicidality regardless of psoriasis severity [39]. Suicidal ideation rates are reported to be from 1-27% [40].

Systematic reviews about the risk of suicide in psoriasis report conflicting results due to a lack of subgroup analyses, high heterogeneity within cross-sectional studies, and variation within suicidal ideation measurement [40-43]. Singh et al. [40] reported that psoriasis doubles the risk of suicidality and Wu et al. [42] reported a higher risk for younger patients but no significant association with gender.

There is limited data on suicidality specific to psoriatic arthritis [20]. A cross-sectional study reported a higher prevalence of anxiety and anhedonia in patients with psoriatic arthritis compared to those with only psoriasis, however, found no difference in lifetime suicidality [44]. Given that an estimated 350 diagnoses of suicidality per year are the result of psoriasis in the United Kingdom, further research with subgroup analyses is required [45].

There is an emerging concern regarding biologic treatment and a potentially increased risk of suicidality specifically for brodalumab and apremilast [46, 47]. There is no established mechanism. Nonetheless, patients are recommended to be counselled on this risk [46-50].

An exploratory analysis of initial phase three trials reports no evidence of causality between suicidality and brodalumab, with Kaplan-Meier curves of time-to-event analyses reporting no relationship between the initiation of brodalumab and suicide [48]. Apremliast is licensed for both psoriasis and psoriatic arthritis [47]. The evidence for a potential causal association between apremilast and suicidality is limited and largely based on the initial phase three trials on apremilast [47, 51]. At week 16 of the placebo-controlled phase, patient reported depression with apremilast was 1.4% compared to 0.5% with placebo [51]. A recent 5-year cohort study found no evidence of increased risk of suicidality with apremilast [52].

Substance Use and Addictive Behaviours

Rates of alcoholism and smoking are higher in psoriasis patients compared to the general population [53-55]. This can be attributed to their use as maladaptive coping mechanism for managing the psychological distress of this chronic skin condition [9]. Both smoking and alcohol use are considered potential risk factors for the onset of psoriasis [1].

The association between smoking and a higher severity of psoriasis is well established through observational studies. These may be biased through confounders such as depression [55-58]. A higher intensity of smoking (over 20 cigarettes per day) is associated with a two-fold increase in psoriasis severity [59]. Smoking has also been reported to be a major risk factor for lack of response to anti-TNF treatment [60].

The evidence suggesting alcohol as a risk factor is conflicting. A prospective cohort study of female nurses found that alcohol use increases risk of psoriasis compared to controls [61]. Conversely, Wolk et al. [62] found a significant association between alcohol consumption and psoriasis only in male participants. Conflicting results may be explained by difference in measurement of alcohol intake and bias through retrospective patient-reported alcohol intake [54]. A recent Mendelian randomization study found no causal relationship between alcohol intake and psoriasis [58].

Both smoking and alcohol use are associated with a lack of adherence to treatment leading to poor clinical outcomes and further driving substance misuse as a coping strategy [58, 63, 64]. Further research on the relationship between alcohol consumption and psoriasis is required.

It is imperative to take into consideration that addiction can take many forms beyond smoking and alcohol use [66]. Research on other forms such as gambling, illicit drug use, and food addiction have not been as extensive and is mainly based on questionnaires in cross-sectional studies, heavily susceptible to recall bias and potential under-reporting of illegal substances [67, 68].

In the US, a cross-sectional study of 392 patients and 14,572 controls investigated the prevalence of illicit drug use in psoriasis patients and found associations between psoriasis and cocaine, heroin, and regular cannabis use [68]. Two cross-sectional studies in Germany investigated the prevalence of the 6 most common forms of addiction: smoking, alcohol, gambling, illicit drugs, and food [66, 67]. Both studies demonstrated that, compared to controls, there are significant higher rates of alcohol (p<0.005), smoking (p<0.001) and illicit drug use (p<0.001) [66]. Despite a higher BMI, food addiction was less prevalent in the psoriasis population [67]. However, logistic regression analysis revealed a positive relationship between food and BMI. Patients of a younger age were found to have a higher chance of developing any addiction [67]. Gambling was assessed using the ‘Gamblers Anonymous Twenty Questions (GA-20) which is limited to casinos or gambling halls. The exclusion of online gambling may lead to under-reporting and may not fully capture the extent of gambling addiction, especially in younger populations [66].

Of all addictions, only alcohol use and illicit drug use were associated with disease severity measured by PASI [66]. These results may be limited by the fact that the PASI score was only being assessed on the day of the questionnaire. Previous or pre-treatment PASI scores were not considered. Co-morbidities, especially addictions, are developed over a longer period as a mechanism of coping – not only over the time of a flare-up period. Hence, further studies should utilise the ‘PeakPASI’, which is the highest documented PASI score in a patient, to fully understand and provide valuable insights into the development of addiction-based co-morbidities as a coping mechanism in psoriasis [66].

Overall, more research is needed to fully understand the relationship between psoriasis and different forms of addiction and to identify effective prevention and treatment strategies for these comorbidities.

Quality of life

Patients with psoriasis report a significant impact on their quality of life. The World Health Organisation (WHO) describes the quality of life as “an individual’s perception of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. It is a concept affected by the person’s physical health, psychological state, personal beliefs, social relationships and relationship to salient features in their environment” [68].

Objective measures of quality of life (QOL) are important when assessing psoriasis patients, as the high prevalence of alexithymia may impair clinicians’ ability to ascertain the extent of the psychological impact of the disease. As results are not uncommonly higher than projected, and not always comparable to the severity of patient’s skin disease, measuring the extent of skin disease is not an accurate marker for assessment of quality of life [4].

High scores on quality-of-life assessments should prompt the assessing clinician to consider whether the patient may benefit from psychological intervention. Importantly, for patients on systemic and biologic therapy, QOL represents important endpoints in assessing treatment response and the results of certain therapies.

QOL questionnaires in dermatology are generally categorised as general health, dermatology-specific and disease-specific questionnaires. General health questionnaires aim to assess the overall physical and psychosocial factors. Skin-specific questionnaires can be more helpful, and efforts have been made to devise psoriasis-specific questionnaires to generate more relevant and meaningful information. These can be used in combination with general health questionnaires to provide a better understanding of the disease impact.

Examples of some of the most used questionnaires in psoriasis are listed below

QOL questionnaires

• Salford Psoriasis Index
• Dermatology Life Quality Index (DLQI)
• Hospital Anxiety and Depression Scale (HADS)

Other questionnaires that can be used include those psoriasis patients with joint disease include:

• Psoriasis Epidemiology Screening Tool (PEST)

Alexythmia

Alexithymia is the difficulty in identifying, expressing, and describing one’s feelings. An observational study measuring alexithymia using the validated Toronto Alexithymia Scale [69] in a large cohort of psoriasis patients showed a 24.8% prevalence in this group (compared to approximately 5–10% in the general population) [70]. These patients had more severe disease, significantly reduced quality of life, greater prevalence of anxiety and depression, a higher rate of alcohol dependence, and reduced work productivity. This means, alexithymia can make it problematic for clinicians to determine the true effect of the patient’s psoriasis on their life.

Physical factors

The physical factors (table 7.1) in psoriasis can have a severely harmful effect on quality of life, with studies reporting that two-thirds of patients feel the negative physical impact of psoriasis in their day to day lives. This increases to up to 80% in those with severe disease. The physical symptoms of their skin are a significant factor in the negative effects on quality of life, and these include itching, pain, irritation, and the functional inability of various joints. In addition, the physical impact of co-existing psoriatic arthritis has the potential to cause devastating effects on quality of life. Other associated comorbidities such as obesity, metabolic syndrome, and autoimmune conditions such as inflammatory bowel disease, may all result in physical and consequent psychosocial morbidity [4].

Pruritus

Pruritus remains an under-recognised symptom in psoriasis, yet its prevalence and effect are substantial. Studies report that between 67% and 77% of patients with psoriasis have symptoms of pruritus which are significant and arise daily [71]. The magnitude of pruritus does not appear to always correlate to clinical severity. It is exacerbated by heat, skin dryness, sweating and importantly, stress. There is a known association between pruritus in psoriasis and the risk of depression, again leading to a deleterious cycle of worsening psoriasis and mental health. In a survey of 104 patients with psoriasis, 30% of patients reported pruritus to be the worst physical factor, a symptom that is often under-estimated in this condition [4].

Table 1. Physical symptoms of psoriasis [4]

Skin symptoms:

• Itching

• Skin shedding

• Tightness

• Redness

• Dryness

• Bleeding

• Pain

Functional impairment:

• Self-care

• Activities of daily living

• Occupational factors

Sexual dysfunction

Sleep disturbance

Functional impairment

Functional impairment in psoriasis is common, especially in patients with psoriatic arthritis and particularly seen when it affects the palms and soles; the consequent physical disability from pain results in higher levels of functional impairment. This, in addition, to nail involvement has been shown to limit the ability to self-care and perform basic activities of daily living. These restrictions result in psychological distress and isolation [72].

These physical factors can have significant sequelae, ranging from the inability to carry out simple activities of daily living, through to occupational difficulties which can be so severe as to render patients unable to work. These effects can exacerbate the condition and can lead to social isolation and a downward spiral of psychological distress and worsening of the skin manifestations of psoriasis [72].

Sexual Dysfunction

Psoriasis is reported to interfere with sexual relations in 35–50% patients. This appears to be more prevalent in female patients and can present in a variety of ways. The physical involvement of the genital skin can make sexual intercourse painful or uncomfortable. A large study of 354 patients revealed that 39% patients experienced pain, 42% dyspareunia and 32% worsening of genital psoriasis after intercourse [73]. The psychological effect of skin involvement can make it difficult for patients to enter relationships, due to self-consciousness or fear of stigma. Additionally, psoriasis causes a decrease in libido in a large proportion of patients. Those who report sexual dysfunction from psoriasis have more symptoms of depression [4]. It is apparent that psoriasis has a profoundly negative impact on sexual health and satisfaction.

Sleep Disturbance

Sleep disturbance is common and variable in psoriasis, with reports ranging from 5.9% to 44.8% prevalence. The skin has an important role in mediating core body temperature and acts as a primary circadian mediator to reduce this temperature at night as part of normal sleep initiation. The normal and physiological reduction in core body temperature occurs due to a drop in metabolic heat generation, increase in blood flow to the skin, and distal vascular dilatation; these result in the dissipation of heat and an increase in trans-epidermal water loss. In psoriasis, thermoregulation via the skin is impaired, and therefore sleep initiation may be compromised as a result [74].

Cutaneous symptoms including pruritus and pain are well recognised in psoriasis (see section 4 “Physical Factors”). Pruritus is often said to be worse towards the end of the day. This symptom is also regulated by circadian mechanisms and the threshold for symptoms is lower in the evening due in part to a reduction in cortisol levels, increase in temperature, and reduced epidermal barrier function. This therefore manifests as an exacerbation of cutaneous symptoms at night, which causes disturbed sleep.

Many of the associated comorbid conditions can also result in sleep disturbance; for example, there is a higher prevalence of obstructive sleep apnoea in psoriasis [74] with studies reporting 36%–81.8% in psoriasis, compared with 2%–4% in the general population. There is also a known increased prevalence of restless leg syndrome (15%–18% in psoriasis patients compared with 5%–10% in the unaffected population). The increased prevalence of psychiatric comorbidity (see section 2 “Psychiatric Comorbidities”) is also a significant contributor to problems with sleep.

psychosocial factors

The psychosocial aspect of psoriasis has been reported by patients to be one of the worst aspects of their condition, resulting in a severely negative impact on the quality of life [75]. The extent to which this occurs differs widely and does not always correlate with the extent of disease. The psychosocial implications are varied and include negative emotional effects on the self, as well as impacting their interactions with their close and wider social network.

Psychosocial Factors and Schemas

The profound psychological impact of psoriasis and the role of distress in the onset, exacerbation and persistence of the condition is well-recognised. The common and recurrent patient reported themes in studies include negative effects on self-confidence, feelings of shame, embarrassment, and a lack of self-esteem. In a large study of 217 patients, over 50% reported feeling self-conscious around strangers [76]. Research has shown that patients with psoriasis use anticipatory and avoidance behaviours as a coping mechanism. Schemas are engrained cognitive and emotional patterns which influence the individual’s approach to life; they are now recognised as an important part of the psychological sequelae of psoriasis (table 9.1). The early maladaptive schemas (EMS) are those which originate in childhood and develop in adulthood [77]. Schemas are particularly difficult to challenge as they are deeply held beliefs that are consolidated through repeated and often self-fulfilling experiences.

Table 2, Schema in psoriasis [4]

Early maladaptive schemas in psoriasis (Mizara et al.2012)

Emotional deprivation

Social isolation

Defectiveness

Failure

Vulnerability to harm

Subjugation

Emotional inhibition

Social Factors

Psoriasis affects many patients’ ability to function to their best potential in social environments (table 9.2). The fear of stigma plays a large part in this (see section 6.1). Numerous studies have shown that patients with psoriasis try to hide their skin symptoms, and many report avoiding social activities that involve showing their skin, such as swimming, with one study quoting that 83% of patients would ‘often’ or ‘always’ avoid these situations [78]. Social functioning appears to be more severely affected in psoriasis than in other chronic conditions such as hypertension and arthritis, reflecting the visible nature and stigma associated with this skin condition.

Table 3. Psychosocial impact of psoriasis on quality of life [4]

Negative psychological effects on the patient:

• Self-image

• Self-esteem

• Self-wellbeing

• Early maladaptive schemas

Negative effects on social functioning:

• Relationships with friends and family

• Sexual relations

• Day to day encounters with the general public

• Occupational effects

The ability to work and study can also be severely impacted by psoriasis; in a large survey of 369 patients with psoriasis in the UK, one-third attributed ‘not working’ to their psoriasis [79]. Over 17% of 18–54-year-old patients with psoriasis report a psychological impact of psoriasis on their work, and 23% reported that their psoriasis had an impact on the choice of their career [79]. Of those who do work, over half report that the quality of their work life is negatively impacted due to their psoriasis [79].

Stigma

Stigma is defined as ‘a mark of disgrace which sets people apart from each other’. Many patients with psoriasis report experiencing stigma from their skin, which can have a profound effect on their social interactions and general quality of life. This effect is most pronounced in the 18–45-year-old age category, correlating with the age in which people are most likely to be socially and professionally active [80].

The visible nature of psoriasis renders patients exposed and vulnerable to external perceptions and misconceptions. Many patients report experiences of being publicly rejected due to a public belief that the condition is contagious, or simply due to fear or lack of knowledge. This results in feelings of shame and lack of self-worth, with consequent avoidance, isolation, and social withdrawal. In a large study of patients with moderate-to-severe psoriasis, 25% reported an episode where someone ‘had made a conscious effort not to touch them’. Those with visible affected skin perceive their condition to be more disabling and have higher levels of self-reported physical morbidity [80].

Ginsburg et al. identified six dimensions to stigmatisation (table 9.3) [81]. There appears to be a significant variation in the frequency with which these feelings are experienced, and contradictory feelings could be experienced simultaneously. The group also investigated predictors for the components of stigma experienced. They found that age of onset, bleeding, employment, duration of experience, and rejection were the strongest predictors of stigma. Of these, bleeding was the most strongly predicting factor and correlated highly with stigma. Stigma was also associated with poor adherence to treatment and worsening of their skin condition.

Table 4. Components of stigmatisation (Ginsburg and Link 1989) [82]

Anticipation of rejection

Feelings of being flawed

Sensitivity to others’ attitudes

Guilt and shame

Secretiveness

Positive attitudes

Treatment

Psoriasis is a complex condition with a significant psychological overlay (Fig 10.1). Therefore, just simply treating the skin and joint symptoms is not always sufficient; often a more holistic approach, including a focus on psychological health, is required to successfully manage these patients. Due to the chronic and relapsing nature of the condition, and the fact that many patients have been undertreated for years, it can be difficult for clinicians to encourage patient adherence and positivity to treatment [4].



Fig 1. Factors leading to exacerbation of psoriasis [4]

Treatment of the Skin and Joints

Treatment of the skin is generally instigated in a stepwise approach and should be tailored to the individual patient depending on the extent of disease, severity, and effect on the quality of life. This involves topical treatments, phototherapy, systemic and biologics [4]. Further details are outside the scope of this paper. There is plenty of evidence from every day clinical practice that when the skin is treated, patients are generally more satisfied and have an improved quality of life. However as mentioned previously, this is not always a predictable response and sometimes quality of life measures reveal that the patient may still be suffering from significant psychological morbidity despite an improvement in their physical health. Joint disease can be treated simultaneously with systemic and biologic agents and requires close collaboration with rheumatologists.

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) is a psychological intervention that involves identifying and challenging unhelpful thoughts and behaviours and learning competing coping mechanisms in order to break the negative cycle [82]. It is well established that stress and distress are frequent exacerbators of psoriasis, but this recognition can also cause patient anxiety which can perpetuate a worsening of their physiological and psychological state. CBT aims to break this cycle. There is evidence that just 6 weeks of weekly CBT sessions combined with standard treatment, versus standard treatment alone, carries a significant improvement in the clinical severity of the skin, and ameliorates symptoms of anxiety, depression, stress, and disability [83]. In one study, these results persisted at the 6-month follow-up, with 64% of patients achieving a greater than 75% improvement in the clinical extent of their psoriasis, compared with 23% in the control group [84]. Other evidence suggests that CBT is effective at improving anxiety levels but less effective at treating depression. Another study has shown that just seven psychotherapy sessions delivered over 12-weeks resulted in clinical improvement although the perception of stress remained similar. Promising results have also been demonstrated using an internet-based electronic CBT intervention, with an improvement in anxiety and quality of life.

Psychotropic Medication

Psychotropic medication includes any medication which affects the mind, emotions, or behaviour. There is limited high-level evidence for the use of psychotropic medication in psoriasis; however, identifying and treating comorbid psychiatric diagnoses is anecdotally known to be beneficial [4]. In one double-blind placebo-controlled study of 60 patients with psoriasis, patients were randomised to moclobemide (a monoamine oxidase inhibitor antidepressant) plus topical corticosteroids, or to topical corticosteroids alone [78]. Those treated with the antidepressant and topical corticosteroids showed improvements in the clinical severity of psoriasis as well as in depression and anxiety. Another small observational study of 38 patients with psoriasis treated with anti-TNFα treatment compared concurrent treatment with escitalopram (a selective serotonin reuptake inhibitor antidepressant) and psychotherapeutic treatment, compared with psychotherapeutic treatment alone [78]; those treated with escitalopram plus psychotherapeutic treatment had greater improvements in the clinical severity of their skin, as well as greater reduction in symptoms of anxiety and depression.

Clinicians should however be aware that there are reports of psychotropic medication resulting in flaring or inducing psoriasis, and these include but are not limited to lithium (a well-recognised culprit), fluoxetine (several case reports), beta-blockers, and bupropion [4].

CONCLUSION

Psoriasis is a complex to treat condition due to the multitude of co-morbidities (both physical and psychosocial) which have a profound impact on quality of life and treatment outcomes. Effective treatment requires a holistic approach. Psychological co-morbidities have a large impact on treatment adherence and efficacy. Patients at risk of psychological distress should be identified and supported through simultaneous management of both skin disease and mental health, disrupting the negative cycle between the two.

 

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From: Proceedings of the The 6th IFPA World Psoriasis and Psoriatic Arthritis Congress

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Posted on 30 June 202322 November 2024